United States Federation of Small Businesses, Inc.

USFSB Health Insurance Recommendations	Insurance Glossary
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Census Form Part 1

Thank you for your interest in our insurance products. By completing and submitting our company census form, you will receive recommendations and quotes for the products that most closely match your needs.

The first step is to complete your company information and click on the "Submit Census" button at the bottom. You will then need to add information about your employees. All information will be provided to the carrier but otherwise be kept confidential.

Company:

Address:

City:

State: Zip:

Name-Salutation: First: Last:

Phone:

Fax:

Email:

How did you hear about USFSB?

Please describe the nature of your business (examples: Restaurant, Insurance Agency):

Bus.Type:

Indicate your preferred type(s) of health plan(s):
HMO: PPO: EPO: POS: Indemnity: Basic Hospital:

Do you currently have health insurance coverage?

Yes

If yes, who are you currently covered through?

Please prioritize the following using 1 for the most important and 5 for the least important:

Cost:

Deductibles:

Maternity:

Rx:

Retain Current Physician:

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